Financing STI testing among men in China: A mixed-methods study of pay-it-forward monetary donations

Aim: Many STI testing services are underfunded. Pay-it-forward is a strategy to support STI testing that asks participants to donate money to spur others to receive STI testing. To explore factors influencing monetary donations, we performed a secondary analysis of data from a randomized controlled trial that evaluated a pay-it-forward strategy to increase STI testing among men in China. Methods: We used a convergent parallel mixed-methods design to analyze data from the RCT and semi-structured interviews. Correlates of monetary donations were identified using logistic regression. Interview responses were analyzed using thematic analysis using charitable triad theory to explore donor, recipient, and organizational factors influencing donation behavior. Results: A total of 800 men received the pay-it-forward intervention. Overall, 139/718 (19%) made monetary donations, with a mean amount of 3.88 USD. The total value of all donations was 539.4 USD. At the donor level, donation behavior was associated with individual characteristics such as age, gender, and prior testing history. Donors who could identify with or visualize future recipients were also more likely to donate money. At the recipient level, income was not significantly associated with donation. At the organizational level, transparency and clear messaging enhanced trust and facilitated donations. An increased perceived risk of STI infection also motivated donations. Conclusion: Our findings highlight key factors driving donations in a pay-it-forward program. Transparent fund allocation and real-time donor feedback can enhance trust and participation. Clinical trial registration: ClinicalTrials.gov NCT05723263.